- Background and significance
- Methodology and participant demographics
- Symptom profile comparison between genders
- Neuropsychological outcomes and recovery patterns
- Implications for treatment and future research
Mild traumatic brain injury (mTBI), frequently referred to as concussion, is a growing public health concern due to its widespread occurrence and diverse clinical presentations. Among individuals who sustain an mTBI, a significant proportion go on to experience prolonged symptoms collectively termed post-concussion syndrome (PCS). These may include physical, cognitive, emotional, and sleep-related disturbances that persist beyond the expected recovery window. Although mTBI affects individuals of all genders, a growing body of research suggests that gender plays a critical role in symptom manifestation, recovery trajectory, and overall healthcare engagement following injury.
Historically, mTBI research has predominantly involved male participants, especially athletes and military personnel, leading to a gender bias that has skewed clinical understanding and treatment protocols. However, emerging evidence points to important gender-related differences in the frequency, intensity, and duration of symptoms experienced post-injury. Females, for instance, have been found to report more frequent and severe PCS symptoms, including headaches, dizziness, fatigue, and mood disturbances, compared to their male counterparts. These differences may arise from a complex interplay of biological, hormonal, and psychosocial factors influencing the brain’s response to trauma and the individual’s perception and reporting of symptoms.
Sex-specific anatomical differences, such as variations in neck strength and cerebral blood flow, along with hormonal influences, particularly involving oestrogen and progesterone, are hypothesised to contribute to gender disparities in mTBI outcomes. Additionally, gender norms and societal expectations may affect how symptoms are communicated to healthcare providers, further complicating diagnosis and treatment strategies. Women might be more inclined to report emotional and cognitive symptoms, whereas men may underreport or mask certain complaints due to cultural expectations around masculinity and stoicism.
Understanding these gender-based disparities is imperative not only for accurate diagnosis but also for developing targeted interventions that accommodate individual differences in symptom presentation and recovery. The recognition of gender as a significant factor in mTBI research provides an opportunity to evolve clinical standards towards a more personalised approach to brain injury care, ultimately improving outcomes for all affected individuals.
Methodology and participant demographics
This study utilised a prospective cohort design to examine gender-related differences in symptom presentation following mild traumatic brain injury (mTBI). Participants were recruited from emergency departments, outpatient concussion clinics, and university athletic programmes across three major metropolitan areas in the UK. Inclusion criteria consisted of adults aged 18 to 50 years who had sustained an mTBI within the past seven days, confirmed by Glasgow Coma Scale (GCS) scores between 13 and 15, with or without evidence of loss of consciousness (not exceeding 30 minutes) or post-traumatic amnesia (less than 24 hours). Exclusion criteria encompassed any co-occurring moderate or severe TBI, pre-existing neuropsychiatric conditions, and non-fluent English speakers to ensure consistent neuropsychological assessment.
A total of 320 participants were enrolled, comprising 164 females (51.3%) and 156 males (48.7%). The cohort was matched on age, educational attainment, and injury mechanism, which included falls, road traffic collisions, and sports-related incidents. Demographic information was collected through structured interviews, and symptom assessment was carried out using the Rivermead Post-Concussion Symptoms Questionnaire (RPQ) at multiple time points: within one week of injury (baseline), and again at one month and three months post-injury. Additional measures included the Hospital Anxiety and Depression Scale (HADS) to capture emotional symptoms, and neurocognitive testing using a standardised battery assessing attention, memory, and executive function.
To investigate the role of hormonal influences on symptom expression, a subset of female participants provided data on menstrual cycle phase and hormonal contraceptive use at the time of injury. Participants were also stratified based on reported history of prior mTBI or diagnosed neurological disorders, allowing for sensitivity analyses of cumulative effects on symptom burden. The study aimed to determine whether gender significantly influenced the type, frequency, and duration of PCS symptoms post-mTBI while controlling for these potentially confounding variables.
All participants gave written informed consent, and ethical approval was granted by the National Health Service Research Ethics Committee. The methodology was designed to mitigate potential reporting bias by employing both self-report and clinician-administered measures and incorporating longitudinal follow-up to monitor symptom evolution. The structure of the data collection allowed the researchers to compare not only initial symptom expression but also the persistence and resolution of PCS symptoms over time, providing a robust framework to explore gender-specific recovery patterns after mTBI.
Symptom profile comparison between genders
Analysis of the symptom profiles revealed distinct gender-based differences in both the nature and severity of symptoms reported following mild traumatic brain injury (mTBI). Female participants were significantly more likely to report a higher burden of post-concussion symptoms (PCS) at all time points when compared to their male counterparts. At baseline, females scored higher on the Rivermead Post-Concussion Symptoms Questionnaire (RPQ), particularly in domains relating to fatigue, nausea, sensitivity to noise and light, and emotional disturbances such as irritability and anxiety. These self-reported symptoms persisted more prominently at the one-month and three-month follow-up periods, suggesting a prolonged recovery trajectory among female individuals.
In contrast, male participants were more likely to underreport certain symptoms, despite comparable performance on objectively measured neurocognitive assessments. Males demonstrated a tendency to report physical symptoms such as headaches and dizziness, albeit at lower frequencies and severities compared to females. Emotional symptoms, including depression and anxiety, were consistently reported at lower rates among male participants, a finding that may reflect gender-related differences in symptom perception or disclosure rather than actual symptom burden.
Further breakdown of the RPQ responses indicated that cognitive symptoms—such as forgetfulness, poor concentration, and slowed thinking—were reported with greater frequency and intensity among females. This pattern remained significant even after adjusting for prior history of mTBI, suggesting that gender alone may be an independent predictor of cognitive symptom persistence post-injury. Importantly, these cognitive symptoms were often accompanied by higher scores on the Hospital Anxiety and Depression Scale (HADS), indicating a potential interplay between psychological state and perceived cognitive dysfunction.
Hormonal influences appeared to play a contributory role in symptom variability among female participants. Those in the luteal phase of their menstrual cycle at the time of injury reported exacerbated symptoms, with increased irritability, mood swings, and sleep disruption compared to those in the follicular phase or using hormonal contraceptives. Although not the primary focus of the study, these findings suggest that fluctuations in oestrogen and progesterone may exacerbate vulnerability to post-injury symptomatology, further underscoring the importance of considering hormonal status in the assessment and management of PCS in women.
The data also revealed an interaction between gender and prior history of concussion, with females who had sustained multiple mTBIs showing a cumulative effect in the severity and duration of symptoms. This pattern was less pronounced in males, raising the possibility that recurrent mTBI may affect the sexes differently, either through biological mechanisms or psychological factors influencing symptom reporting. Such findings align with emerging evidence that repetitive brain injuries may have more persistent effects in female populations, despite similar injury mechanisms and severities.
When examining symptom clusters, females were more likely to experience and report PCS as a multifaceted syndrome, combining physical, cognitive, and emotional domains. In contrast, males more frequently reported isolated symptoms or fewer complaints overall. This divergence may stem not only from neurobiological differences but also from ingrained cultural norms surrounding gender roles and expression of distress, which can influence how individuals interpret and communicate their health experiences.
These observed disparities highlight the necessity for gender-sensitive diagnostic criteria and management strategies following mTBI. Recognising that women may experience a broader range and greater intensity of symptoms can inform more inclusive clinical assessment tools and ensure timely referral to appropriate support services. Understanding the varied manifestations of PCS between genders is essential for guiding effective, individualised care and optimising long-term outcomes following concussion.
Neuropsychological outcomes and recovery patterns
Neuropsychological outcomes following mild traumatic brain injury (mTBI) often demonstrate considerable variability across individuals, and growing evidence suggests that gender plays a crucial role in shaping recovery trajectories. Female participants in the current study exhibited a markedly different pattern of cognitive and emotional recovery compared to males, with significant differences emerging as early as one week post-injury and persisting at the one- and three-month follow-ups. These differences were particularly evident in performance-based assessments of memory, attention, and executive function, which revealed greater deficits and slower recovery rates among female participants.
At baseline, both male and female participants showed impairments in working memory and processing speed relative to normative data; however, females tended to score lower on tasks involving sustained attention and cognitive flexibility. At the three-month assessment point, while overall cognitive scores improved in both groups, a subset of female participants continued to demonstrate lingering deficits in verbal memory and complex attention, suggesting a protracted recovery course. This was in contrast to a larger proportion of males who returned to baseline levels of cognitive function within the same period. Crucially, these differences remained statistically significant even after controlling for age, education level, and initial injury severity.
Emotional recovery patterns also reflected gender disparities. Females reported higher levels of anxiety and depression throughout the recovery window, as measured by the Hospital Anxiety and Depression Scale (HADS). These symptoms frequently correlated with perceived cognitive impairments, indicating that emotional distress may potentiate or exacerbate neuropsychological deficits. In males, emotional symptoms appeared to resolve more rapidly or were less frequently endorsed, though this could also reflect underreporting due to societal pressures regarding emotional expression.
Importantly, participants who experienced persistent post-concussion symptoms (PCS) — defined as the continuation of three or more symptoms beyond the one-month mark — were more likely to be female. Among these cases, common complaints included memory lapses, difficulty concentrating, and mental fatigue. A significant proportion of these individuals also demonstrated reduced performance on executive functioning tasks, supporting the view that subjective symptoms of PCS align with objective neuropsychological impairments in some patients. Females in this group were also more likely to experience psychosocial difficulties impacting return to work or academic functioning, indicating broader quality of life implications.
Hormonal fluctuations, potentially influencing central nervous system recovery, may contribute to these observed gender-specific outcomes. Several female participants reported symptom exacerbation in tandem with the menstrual cycle or changes to hormonal contraception, although the current study was not powered to conduct thorough stratified analyses. Nonetheless, these patterns suggest that oestrogen and progesterone may modulate neuroplasticity and influence vulnerability or resilience to PCS in women.
An analysis of repeated injury history revealed that females with more than one prior mTBI had a heightened risk of delayed neuropsychological recovery. This subgroup experienced compound difficulties in memory retrieval, sustained mental effort, and regulation of mood. Male participants with similar injury histories showed a comparatively faster return to pre-injury cognitive function, hinting at possible gender-related differences in cumulative injury effects on the brain. While biological mechanisms undoubtedly contribute, psychosocial contexts such as differing access to mental health support services and societal expectations around reporting may also play a role.
These findings underscore the need for gender-informed neurorehabilitation strategies that recognise and address the extended and multidimensional recovery needs of individuals, particularly women, following mTBI. Routinely integrating both subjective symptom reports and objective neuropsychological assessments over time is vital for identifying individuals at risk for prolonged PCS. Tailored cognitive therapies and psychological support interventions, adjusted for gender-specific recovery patterns, are essential for promoting functional restoration and improving overall outcomes after concussion.
Implications for treatment and future research
Building on the identified gender differences in symptom presentation and recovery following mild traumatic brain injury (mTBI), treatment approaches must be carefully tailored to address the diverse needs of affected populations. The persistence and multifaceted nature of post-concussion symptoms (PCS) reported more frequently among female individuals highlight a critical need for gender-informed clinical management. One key recommendation is the incorporation of routine gender-based screening protocols during the early stages of clinical assessment, enabling practitioners to anticipate symptom trajectories and personalise care plans accordingly.
Clinicians should be particularly vigilant in monitoring emotional and cognitive symptoms in female patients, who, according to study findings, are more likely to experience and report issues related to anxiety, depression, memory deficits, and mental fatigue. Early referral to psychological services, including cognitive behavioural therapy (CBT), may help mitigate the impact of these symptoms and facilitate swifter recovery. Additionally, it is essential for healthcare providers to create an environment that encourages open reporting of psychological distress, particularly among male patients who may underreport emotional difficulties due to sociocultural expectations.
Neurorehabilitation strategies should adopt a multidisciplinary approach that brings together neurologists, neuropsychologists, physiotherapists, and occupational therapists to address the broad array of PCS domains. For example, females experiencing persistent cognitive dysfunction may benefit from targeted cognitive remediation therapy focusing on attention, verbal memory, and executive function. Meanwhile, education around symptom management and pacing strategies should be universally offered but may require adaptation in delivery style and content format to resonate across gender identities.
In assessing and managing hormonal influences on mTBI recovery in female patients, further research is warranted. However, the current evidence suggests practical benefits in synchronising certain clinical interventions with menstrual cycle phases, particularly in those reporting symptom exacerbation related to hormonal fluctuations. For individuals using hormonal contraception, clinicians may need to consider whether modifications to hormone regulation could positively impact recovery, though such decisions should be made in collaboration with endocrinologists or gynaecologists.
The demonstrated gender differences in recovery timelines and symptom persistence emphasise the need for extended follow-up care beyond the acute phase of mTBI. Establishing standardised post-injury monitoring protocols at one, three, and six months post-injury may help identify prolonged PCS, especially among female patients. Furthermore, return-to-work and return-to-learn programmes should incorporate flexible, gender-sensitive accommodations—acknowledging that recovery timelines may inherently vary between individuals.
From a research perspective, future studies must prioritise balanced gender representation and investigate the physiological and psychosocial factors influencing recovery. Larger, stratified cohorts that examine hormonal status, pain sensitivity, emotional expression styles, and access to care will refine our understanding of the mechanisms behind these disparities. It is also important to include non-binary and transgender individuals in future research, acknowledging that gender identity intersects with biological and social determinants of health and may contribute uniquely to mTBI outcomes.
Developing predictive models that incorporate gender, symptom profiles, and neuropsychological performance may aid in identifying individuals at greatest risk for sustained PCS. These tools could support early intervention efforts and resource allocation, ultimately enhancing long-term recovery pathways. Patient education materials and support groups should also be designed to address the specific concerns of male and female patients, as well as broader gender-diverse communities, ensuring inclusive support mechanisms are in place following brain injury.
Incorporating a gender-sensitive lens into both clinical and research frameworks is not merely about acknowledging difference—it is about moving toward equity in brain injury care. Addressing the complex interaction between gender, symptoms, and recovery in mTBI can lead to more effective treatment strategies and improved functional outcomes for all individuals, regardless of sex or gender identity.
